May 8: "Care guides'' show another face of health reform

COURTNEY PERRY &#x2022; Special to the Star TribuneBetsy Snyder, a care guide for Allina Hospitals and Clinics, visited with a patient in her waiting room office on Thursday at Abbott Northwestern General Medicine Associates in Minneapolis.

Dr. Richard Adair insisted that they spell it out clearly when the jobs were first posted: No experience required.

The idea was to hire people with no medical background, give them two weeks of training, and send them off to clinics to start seeing patients.

Five years later, these so-called “care guides” are fixtures at more than two dozen Allina Health clinics in the Twin Cities, and groups around the country are calling to find out how the concept works.

The guides are part of a fast-growing, and hotly debated, trend in medicine: Putting people with minimal (if any) medical expertise on the front lines — with titles like patient navigator or coach — to help improve care, and rein in the costs, of patients with chronic illnesses.

The Allina program, which began as a pilot project in 2008, may raise some eyebrows: Most of the care guides are in their early 20s, some in their first jobs out of college.

But new research, which Adair and a colleague will present this week, shows that the care guides have been able to influence patients in ways that doctors alone could not — helping people to quit smoking, get their blood sugar under control, and make other small victories in the daily battle with chronic illness.

One of the frustrations with traditional office visits, Adair said, is that the doctor’s message often evaporates when the patient gets home.

“You can just tell sometimes that you’re not getting through to the patient,” he said. “They’ll give you the old bobblehead response, but they’re not going to do it.”

For people with chronic illness, such as diabetes or heart failure, skipping a medication or ignoring their diet can be particularly dangerous.

But it happens all the time, he said. “I thought, ‘what could we do differently?’ ”

Hiring more doctors or nurses, he knew, would be prohibitively expensive.

The care guides were his answer. With a $6 million grant from the Robina Foundation in Minneapolis, Allina hired a dozen of them, at the rate of $16 an hour, and set them up in cubicles in clinic waiting rooms. Their job: Meet with struggling patients, go over their doctors’ instructions in detail, and see whether they could help them make progress.

No lab coat

Betsy Snyder, 23, never wears a white coat on the job. She wouldn’t want her patients to get the wrong idea.

“I try to explain that I’m a different type of clinic employee,” said Snyder, who’s been a care guide at the Abbott Northwestern General Medicine clinic in Minneapolis since December.

When she started, Snyder, who graduated from Macalester College last May, went through a two-week medical boot camp. That included three days of classwork (in “disease basics” and electronic medical records) and shadowing doctors, nurses and others around the clinic.

There’s even a one-page “scope of practice” that spells out what they can and can’t do.

It’s OK to give educational handouts, talk about controlling blood pressure and help people shop for medications. But “no medical advice.” If a clinical question comes up, they have to check with a nurse or doctor.

“That part, of not overstepping their boundaries, is important,” Adair said. “We just hammer them on that one.”

One day last week, Snyder met with Bob Bourke, 80, who has diabetes and kidney disease.

“So let’s go over how you’re doing with your goals here,” she said. Checking his electronic medical record, she noted that a recent diabetes test was outside the normal range (“It’s a little bit high”). How was he doing with his medications? At one point, Bourke wondered aloud whether a new drug might interact with his old one, and she deflected the question. “Yeah, I don’t know so much about the interactions,” she said. “But if you had a problem, we could certainly talk to [the] doctor.”

Bourke, who lives in Elko New Market, says working with Snyder has given him a better grasp on his condition.

“You know, the doctor is always busy, the nurse is always busy,” he said. But Snyder has more time to explain things. “That’s what’s good about talking to Betsy,” he said.

Sometimes, Adair said, patients reveal things to care guides that they won’t admit to a doctor or nurse. In one case, an elderly patient had high blood pressure, and Adair was struggling to get it under control. “I changed prescriptions, I added doses,” he said, but nothing worked. A care guide discovered the truth. “He wasn’t taking his medicine, but he would never tell us,” Adair said. The care guide, a woman, persuaded the man to start taking the pills, and his blood pressure fell to normal.

“There was something about her ability to get through to him,” Adair said.

Helping patients reach goals

So far, thousands of patients have gone through the program, and Allina’s own research has found that it’s had a dramatic effect. One study, of 2,135 patients, found they were twice as successful as a control group at meeting their “patient care goals,” such as controlling blood pressure, cholesterol, blood pressure. Some 17 percent quit smoking, compared with less than 1 percent of the controls. They were even less likely to end up in the hospital.

The results will be presented Tuesday at a medical meeting in St. Paul sponsored by the Institute for Clinical Systems Improvement.

Dr. Trissa Torres, who studies health-care innovation nationwide, called it a “very exciting program.” As a senior vice president at the Institute for Healthcare Improvement in Cambridge, Mass., she said such programs are transforming medicine all across the country.

Doctors, she said, often assume that patients ignore their advice because they’re uninformed or unmotivated. “In most cases, it’s neither,” she said. The most successful programs, she said, are designed to help the patient help themselves. The key “is being a really good listener, and meeting people where they are,” she said. And that’s where a layperson may have an advantage over a doctor, she said. “We’re trying to build a bridge between the doctor and patient.”

But critics worry that these strategies could do more harm than good. “I just don’t see how in the world that will ever work,” said Linda Hamilton, president of the Minnesota Nurses Association.

Hamilton said the idea of patient guides or navigators is a good one, but only if they have medical expertise. “You’ve got to have somebody who knows how to ask the right questions,” she said. The biggest risk, she said, is that an untrained person will miss something important, “and somebody ends up really in a mess or hospitalized.”

Dr. Robert Geist, a retired Twin Cities urologist, agrees. “They may be smart kids, but they don’t have the sophistication,” he said. “That would worry me a good deal.” In essence, Geist said, “it’s like having a son, a parent, or good friend to speak with about your health.” While there’s nothing wrong with that, he added, “I don’t know anybody who would buy that service.”

But Dr. Dave Thorson, chair of the Minnesota Medical Association, says this kind of program can be valuable.

“Yes, there are risks,” he said. But he said it’s also a way to improve communication with patients. His own practice, in White Bear Lake, is one of many that uses care managers to stay in touch with patients between visits. At this point, he said, there’s no agreement about how much, or how little, training they need. But there’s little doubt that consumers will see more of them in the future.